Patients Rising was formed to stand up for patients, to advocate for their rights, to help fight for the access to treatments they need and deserve, and to tell the truth about health care. We want to bring you practical news you can use. After all, healthcare represents roughly 1/5 of the U.S. economy.

EPISODE 13

Happy New Year! 2019 has finally arrived. Here at Patients Rising we have lots of goals for the year — all of which revolve around making you a smarter, more organized patient.

My name is Terry Wilcox and I am the co-founder and Executive Director of Patients Rising and Patients Rising Now — both national organizations based in Washington, D.C.

As some of you know, the title of this show has been all over the place, but to start the year, we are locking the title.

“Patients Rising University”.

Patients Rising University is our signature educational program and this weekly live broadcast will focus on teaching you how to navigate your health care as well as highlighting the access barriers and roadblocks you may encounter along the way.

We have a helpline where we love to find out about your access issues or health navigation questions: 1-800-685-2654

Or email us at: AskAccess@patientsrising.org.

Episode 13:

Topic of the Day: a very common condition — knee pain — and the very common surgery that can often follow the progression of that pain — a full or partial knee replacement surgery. We picked this particular surgery because there is such a wide range of out of pocket costs for patients to look at and consider. We think it is a great way to take you through the process.

Our Guest: Our guest is Pat Whitham, she lives in Virginia. Presently she is looking into knee replacement surgery as an option. She has had chronic knee pain and issues for years.

HEALTH HACK: Our health hack today will focus on navigating this process and helping you to get the best care with hopefully the lowest out of pocket costs.

What Gundersen found in this article was that the actual cost is $10,550 at most, including the physicians. The list price was five times that amount. And we say our drug companies are gouging us …

You should expect multiple bills following a knee replacement surgery, including:

Hospital bills

Bills for all treatments you received from the surgeon while in the hospital

Other tasks and procedures performed by the operating room staff (including work done by the anesthesiologist, surgical assistants, physical therapists, and others)

Hospitals will sometimes provide discounts if you don’t have health insurance or aren’t covered by Medicare. Ask about a possible discount or payment plan before scheduling your surgery if you don’t have insurance coverage. You should try to estimate your costs in advance whether or not you have insurance.

Speak with your doctor, a hospital representative, and your insurance provider before surgery to learn the expected average charges for your area. It’s important to know what will be covered and what discounts will be applied.

Once you’ve reached your deductible, Medicare typically pays 100 percent of inpatient charges related to a procedure and the hospital stay. Private insurance plans pre-negotiate fees with hospitals and providers. They usually only pay a percentage of the total charges.

Private insurance varies. It’s important to review your benefits plan before scheduling a knee replacement. Understand your deductible, which providers are in your insurance network, and what services will be covered.

Understanding Your Bill

Bills vary, but here’s what you generally can expect if you receive a knee replacement:

Presurgical preparation

The presurgical evaluation phase consists of a consultation or office visit, imaging, and lab work. The lab work usually includes blood work, cultures, and panel tests.

The number of expected services and the total charges vary by insurance coverage and age group. For example, someone over the age of 65 (usually covered by Medicare) generally requires more lab work than someone under 65. This is because an older adult is more likely to have preexisting conditions that must be understood fully during a preoperative evaluation.

The approximate national average charge for these services, according to what typically occurs within the 90 days prior to surgery, is $1,900 for Medicare patients and $1,000 for those with private insurance.

Hospital stay and surgery

You’ll receive separate bills for a TKR. the hospital will bill you for your hospital stay, time spent in the operating room, and other applicable hospital services, supplies, and equipment used.

Providers will bill you for procedure charges that cover services provided by the surgeon, as well as:

Anesthesia

Anjections

Pathology services

Surgical assistance (for example, operation of computer-aided or other technology)

Physical therapy

Coordination of care

Totals

The average patient out-of-pocket expense in the United States ranges dramatically and ultimately depends on your insurance plan. Medicare patients can expect their out-of-pocket costs to be in the hundreds of dollars.

Those with private insurance can expect these costs to reach into the thousands. Review your plan carefully if you’re covered by private insurance. Remember that your deductible, copay, co-insurance, and max out-of-pocket values will come into play.

Additional costs

Keep in mind that the cost of care and services is only part of the overall expense. For example, your doctor will also probably prescribe special equipment, such as a continuous passive motion machine, walker, or crutches. Most insurance plans and Medicare cover these devices (referred to as “durable medical equipment”). However, they may lead to additional charges that appear on your hospital bill or another bill.

You may also require additional physical therapy or a nurse in your home. Your home may require modifications. This could include installing:

Safety bars and rails

A shower bench

A toilet seat riser with arms

Expect to pay out of pocket if your insurance doesn’t cover home-care services. You should also expect separate bills if you’re unable to return home immediately and are released to a rehab or nursing facility for extra care.

Factor in lost income if you take time off from work for the surgery or during recovery. Talk to your employer and insurance provider to find out if you qualify for any disability insurance options that cover time off work.

Disability insurance is a form of insurance that pays out a partial wage to employees who can’t work because of an injury or disability. It may cover time off needed for surgeries such as TKRs.

Health Hack: Options to save money

Some patients opt to have their TKR performed overseas. Travelling out of the U.S. for medical procedures is referred to as “Medical Tourism”. The cost of the surgery can drop by 50 to 80 percent in countries like Mexico, India, or Taiwan.

If you’re considering taking this route, make sure that the facility is internationally accredited by the Joint Commission International (JCI) before agreeing to the procedure. This means the surgeons are accredited and that the facilities and prosthesis meet the highest standards. Keep in mind that you’ll likely spend several thousand dollars for airline tickets, hotels, and related expenses.

By knowing the costs up front, you can avoid surprises — and potential hardship — down the line.

Remember: be smarter than your insurance company. Know your rights. Know what you are paying for. Get everything you are entitled to within your plan — but doing that takes leg work many of us just skip — which is why with an actual cost of $10,500, knee replacements are costing more than $50,000 on average. We stopped paying attention.

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